Peru

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Focus: HIV prevention and treatment among men who have sex with men (MSM)

Affiliation: Asociación Civil Impacta Salud y Educación; Yale Schools of Public Health and Medicine

Contacts: Dr. Frederick Altice, MD, MA frederick.altice@yale.edu; Jorge Sanchez, M.D., M.P.H. jsanchez@impactaperu.org

Projects: The training site will include Impacta Peru, the countries largest HIV/AIDS Service Organization and research institute that is a member of the AIDS Clinical Trials Group (ACTG), HIV Prevention Trials Network (HPTN) and the HIV Vaccine Trials Network (HVTN).  They have ongoing relationships with many of the country’s largest NGOs that provide HIV prevention and treatment in Peru, the Ministry of Health and Cayetano Herredia School of Medicine.  Drs. Altice and Sanchez have collaborated together since 2010 in these sites, which have served as training sites for numerous pre- and post-doctoral fellows.  The team has conducted bio-behavioral surveillance studies, health services research, interventions that promote HIV testing, linkage and retention in care and other health outcomes.  Specifically, this team has been exploring the impact of alcohol use disorders and drug abuse among men who have sex with men (MSM) because Peru is experiencing a concentrated epidemic among this group. New studies are examining the risk of TB treatment adherence and completion among those with and without alcohol and drug use disorders. Primary and secondary prevention studies are underway, including treatment as prevention and adherence studies using medication-assisted therapy (e.g., naltrexone) and behavioral interventions. In addition, Impacta has relationships with many other universities including University of Washington and UCLA, where there are many active research projects. Drs. Altice and Sanchez collaborate on two active R01 grants from the NIDA and NIAAA and are writing new grants to expand some of this work to TB.  The primary R01 is to expand HIV testing and to examine the impact of acute HIV infection (AHI) on ongoing HIV transmission among MSM.  We will conduct network analyses and study linkage and retention in care after acute diagnosis as well as to examine the impact of “immediate” antiretroviral therapy on reducing onward HIV transmission.  A second aim of this study is to conduct a RCT using extended-release naltrexone (XR-NTX) among MSM with alcohol use disorders who are newly diagnosed and to examine the impact of XR-NTX on retention in care, adherence, viral suppression and HIV transmission.  We are also examining the impact of alcohol, drugs and neurocognitive impairment on HIV treatment outcomes as well as exploring mobile health technologies on improving HIV treatment outcomes. The second R01 is a comparative effectiveness trial comparing a pharmacotherapy versus a behavioral intervention for alcohol use disorders among HIV-infected MSM. The NIDA R01 has two aims:

Aim 1: We will investigate the impact of drug and alcohol use on HIV transmission by examining the role of MSM with substance abuse in transmission clusters identified through partner tracing and phylogenetic analysis. We will estimate the impact of timely ART on the decay dynamics of HIV VL in the genital tract of MSM with acute or recent infection (N≈200), allowing us to better estimate the potential impact of failure to treat and non-adherence during this period. To increase detection of acute and recent infections we will 1) expand community outreach to increase the frequency of HIV testing and to raise awareness of symptoms of AHI, 2) use assays which detect p24 or HIV RNA to rapidly detect AHI using real-time assays, and 3) use computerized real-time record linkage to prior HIV test results to detect recent infections. Data on drug and alcohol use, the frequency of detection of AHI and successful linkage to care and treatment, sexual network analysis including impact of substance use, effect of ART on genital tract viral load, the impact of drug and alcohol use on retention and medication adherence.

Aim 2: We will conduct a 12-month randomized, placebo-controlled trial of NTX-XR among HIV+ MSM in Lima Peru meeting DSM-IV criteria for AUDs to determine the impact of NTX-XR on a) proportion with VL<400 copies/mL; b) retention in HIV care; c) change in CD4 counts; and d) sexual risk behaviors overall and those associated with alcohol use.  Alcohol treatment outcomes will include: a) time to alcohol relapse; b) % heavy drinking days; c) % days of abstinence; and d) lower addiction severity.
The comparative effectiveness trial is not yet underway and is expected to start with intervention adaptation of the Holistic Health Recovery Program, a CDC evidence-based behavioral intervention and will do so to include alcohol use disorders and to be culturally competent in the South American context.   


Webpages for sites and research programs:
Yale:    http://medicine.yale.edu/intmed/people/frederick_altice-3.profile
            http://cira.yale.edu/people/frederick-l-altice-md